Calming the Storm: Psychodynamic Treatment of Panic Disorder

Fredric N. Busch, MD

Dr. Busch is a clinical associate professor of psychiatry at the Weill Cornell Medical College in New York City.

Disclosure: Dr. Busch reports no affiliation with or financial interest in any organization that may pose a conflict of interest.

Please direct all correspondence to: Fredric N. Busch, MD, Clinical Associate Professor of Psychiatry, Department of Psychiatry, Cornell University, 10 East 78th St, Apt. 5A, New York, NY 10021; Tel: 212-734-0257; Fax: 212-734-0257; E-mail: [email protected].

INTRODUCTION

Both pharmacologic^1-3 and cognitive-behavioral treatments^4-6 of panic disorder have been found to be effective in the short-term treatment of panic disorder. However, many patients fail to respond to or are unable to tolerate these treatments.^4-8 Relapse is frequent if medication is discontinued before a prolonged maintenance phase.^9-12 In addition, questions remain about the long-term effectiveness of these interventions.^4,13 In studies of routine care, patients frequently demonstrate persistent symptoms and problems functioning.¹⁴ Finally, these treatments may not be as effective in treating impairments associated with panic disorder, such as occupational dysfunction, relationship difficulties, and diminished quality of life.^15,16 Given the high morbidity and health costs of this disorder,^17-20 it is important to develop the most effective treatments for panic disorder and related impairments.

A commonly used but not well-studied treatment for panic disorder is psychodynamic psychotherapy. The potential value of this treatment is based on the notion that panic patients have a psychological vulnerability to the disorder associated with “personality disturbances, relationship problems, difficulties tolerating and defining inner emotional experiences, and unconscious conflicts about separation, anger and sexuality.”²¹ Psychodynamic treatments focus more on these impairments than cognitive-behavioral and psychopharmacologic treatments, potentially reducing vulnerability to panic recurrence.²¹ The author of this article and colleagues developed a psychodynamic formulation for panic disorder based on psychoanalytic theory, systematic psychological assessments, and clinical observations to guide treatment interventions.^21-23 This article describes psychoanalytic concepts as they relate to panic disorder, followed by a psychodynamic formulation that weaves together neurophysiologic and psychological vulnerabilities to panic.

Psychoanalytic Concepts in Panic Disorder

The Unconscious

According to psychoanalytic theory, symptoms are based at least in part on unconscious fantasies and affects.²⁴ For example, clinical and research observation suggests that panic patients have particular difficulties with angry feelings and fantasies, such as wishes for revenge.^22,23,25 These wishes represent a threat to important attachment figures, thus triggering anxiety. Patients are often unaware of the intensity of these affects and the vengeful fantasies that accompany them. Becoming aware of these aspects of mental life and rendering them less threatening are important components of psychodynamic psychotherapy.

Defense Mechanisms

Fantasies and affects that are experienced as dangerous can be dealt with through the triggering of defenses, that is, mental processes that disguise the fantasies or render them unconscious.²⁶ Clinical and research observations indicate that panic patients employ particular defenses: reaction formation, undoing, and denial.²⁷ Reaction formation and undoing play a particular role for panic patients in that they attempt to convert an angry affect into a more affiliative one, diminishing the threat to an attachment figure. In reaction formation a threatening feeling is replaced by its opposite; negative feelings of panic patients are oftentimes replaced by concern and efforts to help others. In undoing, a negative affect or fantasy is typically taken back in some way. Denial represents a lack of recognition of the presence of a particular feeling or fantasy, such as a patient reporting he was not angry even after someone had done something hurtful to him. It is generally important to bring these defenses to the patient’s attention as they maintain the patient’s avoidance of exploring the frightening feelings and fantasies. For example, a patient who follows the statement “I hate him” by “but I really love him” (an example of undoing), is often trying to avoid the intensity of his angry feelings.

Compromise Formation

A symptom can represent a compromise between a conflicted wish and a defense against that wish.²⁴ Teasing apart the components of this compromise formation can help to understand the meaning of that symptom and the unconscious factors that are triggering it. Thus, panic symptoms can include the wish to be taken care of, a denial of anger through a focus on anxiety or bodily symptoms, and an unconscious expression of anger in the coercive aspect of pressuring others to help.

Self and Object Representations

Particular self and object representations can trigger a susceptibility to certain symptoms. In systematic assessments, panic patients have been found to have views of their parents as having been controlling, temperamental, and critical.^28,29 These expectations of the behaviors of others are internalized. In addition, because of their predisposition to fearfulness, panic patients have a view of others as essential to their safety and well-being. Recognizing these perceptions of self and others can help panic patients understand the danger they experience in communicating wishes to be taken care of as well as angry feelings.

Traumatic and Signal Anxiety

Freud distinguished between “traumatic” and “signal” anxiety.³⁰ In traumatic anxiety, which is related to panic attacks, the ego is overwhelmed by the threat from internal dangers. Signal anxiety, on the other hand, can be viewed as an appraisal system in which small doses of anxiety alert the ego to psychologically meaningful dangers, such as potential disruptions in attachment or the threat from vengeful feelings. Signal anxiety can trigger defenses that act unconsciously to ward off potential dangers. In panic-focused psychodynamic psychotherapy (PFPP), the therapist works with anxiety to help the patient cognitively reappraise the degree of actual danger he is in.

Transference

In the course of treatment, conflicts that the patient experiences as occurring with others will often be mirrored in the relationship with the therapist. For example, a panic patient may feel that a therapist, unable to tolerate the patient’s anger, might become judgmental or rejecting. This phenomenon, referred to as transference, can provide direct access to intrapsychic conflicts and self-and-object representations that underlie panic symptoms. The safe environment provided by a nonjudgmental and collaborative therapist aids in the emergence of transference feelings and fantasies.

Psychodynamic Formulation for Panic Disorder

Busch and colleagues²¹ and Shear and colleagues²² developed a psychodynamic formulation for panic disorder based on neurophysiologic predispositions, psychological findings, and psychoanalytic theory. The formulation posits that certain individuals are susceptible to the onset of panic disorder due to a predisposition to anxiety associated with a fearful temperament described by Kagan and colleagues.³¹ Because of their anxiety, children with this predisposition tend to develop a fearful dependency on others, feeling that the parents must be present at all times to provide a sense of safety. In addition, the dependency on others is a narcissistic humiliation for these children, because feelings of safety often require the caregiver’s presence. This fearful dependency can develop from a biochemical vulnerability or from an early relationship in which the children experience frightening threats or behavior by caregivers. In either case, parents are perceived as “unreliable,” and prone to abandonment and rejection of the child.

In response to perceived rejection or unavailability, and due to the narcissistic injury of dependency, the child becomes angry at his caregivers. This anger is experienced as a danger, as it could potentially damage the relationship with the caretakers upon whom the child depends, increasing the threat of loss and fearful dependency. Thus, a vicious cycle of fearful dependency and anger can occur. The vicious cycle is triggered again in adulthood, when the individual experiences or perceives a threat to important attachment figures. Signal anxiety and defenses are triggered, such as undoing, reaction formation, and denial, in an attempt to reduce the threat from anger and maintain attachments. However, due to the degree of threat from these fantasies, as well as immaturity of the signal anxiety mechanism, the ego is overwhelmed and panic levels of anxiety result. Panic attacks further avert the experience of anger and compel attention from others to attend to the patient’s distress.

Recent developments in psychoanalytic theory elucidate another component of the process of panic onset and persistence. Mentalization describes the ability to understand self and others with regard to motives, desires, and feelings.³² Panic patients may have either a diminished capacity for mentalization in general or specific disruptions in this ability caused by conflicts regarding dependency and angry feelings and fantasies. This lack of access to feelings and fantasies can be viewed as unconscious efforts to “not know” about conflicts in order to avoid the threat to attachment.³³ Greater introspective access and mentalization about emotional states of the self and others helps to relieve these dangers. This can allow panic patients to develop voluntary “top-down” cognitive control over emotional reactions by selectively inhibiting and modifying them.

Panic-Focused Psychodynamic Psychotherapy

Overview of PFPP

As opposed to more traditional open-ended psychodynamic treatment and psychoanalysis, PFPP focuses on panic symptoms and the dynamics associated with panic disorder. Material in the sessions other than panic symptomatology is ultimately related to the dynamics of panic. The treatment follows the overall course of identifying the meanings of panic symptoms; calling attention to defenses that inhibit awareness of frightening feelings, conflicts, and fantasies; and, once made conscious, rendering these feelings less threatening or less toxic. Psychoanalytic techniques of clarification, confrontation, and interpretation are employed in this process.

Phase I

In phase I, the therapist works to identify the specific content and meanings of the panic episode. In addition, the patient and therapist examine the stressors and feelings surrounding the onset and persistence of panic. The patient’s developmental history is reviewed to delineate specific vulnerabilities that may have led to panic onset, such as particular representations of parents, traumatic experiences, and difficulty expressing and managing angry feelings. The therapist’s nonjudgmental stance aids the patient in bringing forth fantasies and feelings that may have been unconscious or difficult to tolerate, such as vengeful wishes or abandonment fears. The information is used to identify the presence of intrapsychic conflicts surrounding anger, separation, and sexuality. The goal of this phase is reduction in panic symptoms.

Phase II

Phase II seeks to address the dynamics that lead the patient to be vulnerable to panic onset and persistence. As noted above, these typically include conflicts surrounding anger recognition and management, separation, and fears of loss or abandonment. These dynamics are addressed as they emerge in the patient’s feelings and fantasies about relationships in their present and past and in the transference relationship with the therapist. The meanings of symptoms and the employment of defenses also continue to play a role in identifying the dynamic constellations. Improved understanding of these conflicts helps patients to prevent the development of the vicious cycle described in the formulation above, reducing vulnerability to panic disorder recurrence.

Phase III

The termination phase provides an opportunity to work with the patient’s conflicts with anger and separation as they emerge in the context of ending treatment. Patients can experience and articulate their feelings about loss directly with the therapist. This increased awareness and understanding allows for better management of these feelings and the capacity to avert the development of more severe panic states. An ability to express anger in ways that feel safe is an important development in the treatment. Increased assertiveness and the capacity to communicate about conflicts in relationships improves quality of life and reduces panic vulnerability.

Conducting Treatment with PFPP

Psychoanalysis and psychodynamic psychotherapy have typically been thought to be indicated for patients who enter treatment with a particular set of qualities that includes being verbally skilled, psychologically minded, and curious about the origins of their symptoms. Panic patients, however, with their tendency to experience conflicts and affects as focused in their bodies, have limited verbal access to their intrapsychic life and may be frightened to pursue the origins of their problems. The author of this article and colleagues have found that patients without these skills can obtain relief of symptoms from PFPP.^34,35 A case example illustrates some of the aspects of treatment with this approach.

Engaging the Patient

Several factors enable PFPP to work as a short-term treatment or as an intervention that can help people with little exposure to psychotherapy. This treatment includes a component of psychoeducation, not only about panic disorder, but also about the psychodynamic model and how it operates. In early sessions the therapist focuses on exploring the circumstances and feelings preceding panic onset. Patients become engaged with the treatment as they see the relationship between their symptoms, the stresses preceding onset, the feelings surrounding panic, and their developmental history.

Ms. A was a 43-year-old married woman with two children who described the onset of panic attacks 1 month prior to consultation. She presented with a symptom picture that met criteria for panic disorder along with mild symptoms of depression. She recalled a series of panic attacks just after leaving home for college, but these had resolved spontaneously. At first Ms. A described her panic as having emerged out of the blue. However, on exploration the therapist learned that the initial panic attack occurred after an intense conflict with her 15-year-old daughter, the older of two siblings. Ms. A struggled with how to manage her daughter and saw herself as unable to set limits. She viewed limit setting as being “too mean.” Ms. A quickly grasped that her panic was likely related to these conflicts and her difficulty managing them. She noted that she was “not very assertive” and always had difficulty confronting others.

Following this initial link of the onset of symptoms to family conflicts, Ms. A became very curious about the sources of her problems. The discussion about her daughter reminded her of her problems with her alcoholic father, who had a severe temper problem. The therapist wondered if Ms. A was frightened of expressing any disagreement with him.

Ms. A responded: “Yes, I think I was scared of that. I am always trying to be nice to people. I think that will get them to like me. But I am not sure that it is really helping my daughter to do that.” In this instance, Ms. A was describing reaction formation, in which her anger toward her daughter was converted into becoming “too nice.” She then noted: “I realize I should be setting better limits. Yesterday when I stood my ground with her I felt so much better.”

This information, presented in the first two sessions of Ms. A’s treatment, already provided valuable insights into the origins of her panic disorder. Such triggers included the stress of the conflict with her daughter, difficulties with her management of limit setting, and her fears of getting angry.

Transference

As treatment progresses, the therapist has more opportunities to explore conflicts as they emerge in transference. Oftentimes, these occur in the context of angry feelings toward or separation fears from the therapist.

In a later session, Ms. A complained about an incident with her daughter, and referred to her as “difficult.” The therapist remarked that her view of her child had partly to do with her own behavior, because she was aware that when she set proper limits, her child responded. Although she did not state this during the session, she experienced her therapist’s comments as suggesting she was a bad mother, unwilling to take responsibility for her parenting. She became anxious after the session. That evening she asked her husband to comfort her but he responded that he had had a stressful day and wanted to read the paper. Subsequently, she had the onset of a panic attack. The following session the therapist and patient were able to determine that the patient was quite angry at her therapist and husband, and her conflict about her anger triggered the attack.

Working Through and Termination

Working through involves identifying the presence of conflicts in different areas of the patient’s life, allowing increased understanding of feelings and fantasies. These areas include the patient’s relationship with the therapist and others as well as the patient’s internal fantasy life. For example, Ms. A realized her unassertiveness came from several sources, including fear of her temperamental father, fear of her sister who was more aggressive and bolder, and identification with her mother who was also unassertive and would not confront her father about problems. Each of these instances helped to elucidate the patient’s worry that asserting herself would lead to disruptions in her relationships. In fact, she felt that being the “nice girl” maintained others’ interest in her.

Termination provides an important opportunity for looking at these conflicts directly in the relationship with the therapist. Anger at and fear of losing the therapist will often intensify at this point, highlighting conflicts that emerged earlier in the treatment. For example, in short-term (24-session) PFPP treatments, patients were typically pleased about the progress they had made, but were often able to express concern and frustration with the therapist about ending treatment.^34,35

Research on Psychodynamic Treatment of Panic Disorder

As is generally the case with psychodynamic psychotherapy or psychoanalysis, there have been few systematic studies using manualized treatments for panic disorder. Wiborg and Dahl³⁶ conducted a randomized, controlled trial of a manualized form of psychodynamic psychotherapy along with clomipramine compared to clomipramine alone. The 3-month weekly psychotherapy combined with medication reduced relapse at 18 months compared to patients treated with clomipramine alone (9% vs. 91%).

An open trial of PFPP was conducted with this approach consisting of 24 sessions over a 12-week period.^34,35 Of 21 patients meeting Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition (DSM-IV)³⁷ criteria for panic disorder, there were 4 dropouts. Sixteen of the remaining 17 patients had remission of panic and agoraphobia, as well as significant quality-of-life improvements. These gains were maintained at 6-month follow up. Notably, the 8 subjects who had also had comorbid major depressive disorder experienced relief of these symptoms as well. Although not a randomized controlled trial, the study suggested that PFPP can provide significant relief of panic symptoms. A randomized controlled trial comparing PFPP to applied relaxation therapy has been completed, but as of this writing the results have not been published.

Conclusion

Given that panic disorder remains a significant public health problem, it is important to continue to develop approaches to its treatment. PFPP is a useful alternative or adjunct to cognitive-behavioral therapy and/or medication. PFPP addresses intrapsychic conflicts, defense mechanisms, developmental factors, and transference issues not likely to be focused on in other treatments. Thus, this approach may affect psychological factors that lead to vulnerability to recurrence of panic or other difficulties associated with panic disorder. An open trial demonstrated positive results. A completed placebo-controlled trial should shed further light on the effectiveness of this treatmentmedical costs.

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